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A total of 325 room observations were conducted at 2 sites; 79.7% occurred outside and 20.3% inside the room. The researchers observed 283 failures, including 102 violations, 144 process or procedural mistakes, and 37 slips. Violations included entering rooms without some or all recommended PPE; during PPE removal, mistakes were frequently observed, as well as during encounters with challenging logistical situations, such as badge-enforced computer logins. Touching one’s face or clean areas with contaminated gloves or gowns were included as slips. The likelihood of resulting in self-contamination was considerable for each of these active failures.

“The factors that contributed to these failures varied widely, suggesting the need for a range of strategies to reduce potential transmission risk during routine hospital care,” the authors write.